Onset of bipolar disorder during adolescence increases the risk of school failure, out-of-home placement, drug abuse and addiction, and suicide. In adolescents, bipolar disorder is often accompanied by delusions, hallucinations, or severe assaultive or destructive behaviors that require acute treatment with adjunctive antipsychotic medication in addition to a mood stabilizer. There are no data on when to withdraw antipsychotic medication or whether to withdraw it at all. Although it is important to identify patients who could be maintained on lithium alone to decrease the risk of developing long-term adverse effects such as tardive dyskinesia (TD), it is also important to prevent disruptive recurrences of episodes of illness. There is a high rate of failure on lithium maintenance treatment in general. For adolescents who have had psychotic features or assaultive, destructive behavior as part of their mania, continued adjunctive antipsychotic medication may offer additional prophylactic efficacy. In addition, a lower risk of TD with the novel antipsychotics may alter the risk: benefit ratio in favor of longer-term antipsychotic treatment.